| Left: | US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference) |
| Right: | SPLDocumentReference (http://hl7.org/fhir/us/spl/StructureDefinition/SPLDocumentReference) |
| Error | StructureDefinition.url | Values for url differ: 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference' vs 'http://hl7.org/fhir/us/spl/StructureDefinition/SPLDocumentReference' |
| Error | StructureDefinition.version | Values for version differ: '7.0.0' vs '0.2.1' |
| Information | StructureDefinition.name | Values for name differ: 'USCoreDocumentReferenceProfile' vs 'SPLDocumentReference' |
| Information | StructureDefinition.date | Values for date differ: '2023-10-17' vs '2024-12-10T07:56:13+00:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International / Cross-Group Projects' vs 'HL7 International / Biomedical Research and Regulation' |
| Warning | StructureDefinition.fhirVersion | Values for fhirVersion differ: '4.0.1' vs '5.0.0' |
| Information | StructureDefinition.definition | Values for definition differ: 'A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.' vs 'A reference to a document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this 'document' encompasses *any* serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.' |
| Information | StructureDefinition.comment | Values for comment differ: 'The only time that a resource does not have an id is when it is being submitted to the server using a create operation.' vs 'Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.' |
| Information | StructureDefinition.comment | Values for comment differ: 'Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.' vs 'Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.' |
| Information | StructureDefinition.comment | Values for comment differ: 'Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a 'text blob' or where text is additionally entered raw or narrated and encoded information is added later.' vs 'Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a 'text blob' or where text is additionally entered raw or narrated and encoded information is added later.' |
| Information | StructureDefinition.definition | Values for definition differ: 'These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.' vs 'These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.' |
| Information | StructureDefinition.comment | Values for comment differ: 'This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.' vs 'This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.' |
| Information | StructureDefinition.short | Values for short differ: 'Additional content defined by implementations' vs 'Extension' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' vs 'May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'Other identifiers for the document' vs 'Business identifiers for the document' |
| Information | StructureDefinition.definition | Values for definition differ: 'Other identifiers associated with the document, including version independent identifiers.' vs 'Other business identifiers associated with the document, including version independent identifiers.' |
| Information | DocumentReference.identifier | Element minimum cardinalities differ: '0' vs '1' |
| Warning | DocumentReference.status | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'preliminary | final | amended | entered-in-error' vs 'registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown' |
| Error | DocumentReference.docStatus | Unable to resolve left value set http://hl7.org/fhir/ValueSet/composition-status|4.0.1 at DocumentReference.docStatus |
| Warning | DocumentReference.category | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | DocumentReference.category | Element minimum cardinalities differ: '1' vs '0' |
| Warning | DocumentReference.subject | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | DocumentReference.subject | Element minimum cardinalities differ: '1' vs '0' |
| Information | DocumentReference.date | Element minimum cardinalities differ: '0' vs '1' |
| Warning | DocumentReference.author | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' vs 'May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'replaces | transforms | signs | appends' vs 'The relationship type with another document' |
| Error | DocumentReference.relatesTo.code | Unable to resolve left value set http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 at DocumentReference.relatesTo.code |
| Information | StructureDefinition.definition | Values for definition differ: 'A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the 'reference' to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.' vs 'A set of Security-Tag codes specifying the level of privacy/security of the Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the data elements in DocumentReference, while DocumentReference.securityLabel contains the security labels for the document the reference refers to. The distinction recognizes that the document may contain sensitive information, while the DocumentReference is metadata about the document and thus might not be as sensitive as the document. For example: a psychotherapy episode may contain highly sensitive information, while the metadata may simply indicate that some episode happened.' |
| Information | StructureDefinition.definition | Values for definition differ: 'The document and format referenced. There may be multiple content element repetitions, each with a different format.' vs 'The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata.' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' vs 'May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.definition | Values for definition differ: 'The document and format referenced.' vs 'The document or URL of the document along with critical metadata to prove content has integrity.' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' |
| Error | DocumentReference.content.attachment.contentType | Unable to resolve left value set http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 at DocumentReference.content.attachment.contentType |
| Information | DocumentReference.content.attachment.data | Element minimum cardinalities differ: '0' vs '1' |
| Warning | DocumentReference.content.attachment.url | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.comment | Values for comment differ: 'The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.' vs 'The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R5/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.' |
| Information | StructureDefinition.short | Values for short differ: 'Clinical context of document' vs 'Context of the document content' |
| Information | StructureDefinition.definition | Values for definition differ: 'The clinical context in which the document was prepared.' vs 'Describes the clinical encounter or type of care that the document content is associated with.' |
| Warning | DocumentReference.context | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | DocumentReference.context | Element maximum cardinalities differ: '1' vs '2147483647' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/DocumentReference | ||
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| |
| date | 2023-10-17 | 2024-12-10T07:56:13+00:00 |
|
| description | The US Core DocumentReference Profile inherits from the FHIR [DocumentReference](https://hl7.org/fhir/R4/documentreference.html) resource; refer to it for scope and usage definitions. This profile sets minimum expectations for searching and fetching patient documents including Clinical Notes using the DocumentReference resource. It specifies which core elements, extensions, vocabularies, and value sets **SHALL** be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. Before reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of the US Core DiagnosticReport Profile for Report and Note exchange and the US Core DocumentReference Profile. | A profile that represents the SPL document that was either created by or was the source for the Organization FHIR Bundle. |
|
| experimental | false |
| |
| fhirVersion | 4.0.1 | 5.0.0 |
|
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreDocumentReferenceProfile | SPLDocumentReference |
|
| publisher | HL7 International / Cross-Group Projects | HL7 International / Biomedical Research and Regulation |
|
| purpose | |||
| status | active | ||
| title | US Core DocumentReference Profile |
| |
| type | DocumentReference | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | http://hl7.org/fhir/us/spl/StructureDefinition/SPLDocumentReference |
|
| version | 7.0.0 | 0.2.1 |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 DocumentReference | 0..* | DocumentReference | A reference to a document | C | 0..* | DocumentReference | A reference to a document docRef-1: facilityType SHALL only be present if context is not an encounter docRef-2: practiceSetting SHALL only be present if context is not present | ||||||||||
 id | Σ | 0..1 | id | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (required): IETF language tag for a human language
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier |
| ||||||||||||
| identifier | SΣ | 0..* | Identifier | Other identifiers for the document | SΣ | 1..* | Identifier | Business identifiers for the document |
| ||||||||
| status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: ?? (required) | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: ?? (required): The status of the document reference. Required Pattern: current |
| ||||||||
| docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: ?? (required): Status of the underlying document. | Σ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: ?? (required): Status of the underlying document. |
| ||||||||
| type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: ?? (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: ?? (preferred): Precise type of clinical document. | |||||||||
| Slices for category | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: ?? (example): High-level kind of a clinical document at a macro level. | Σ | 0..* | CodeableConcept | Categorization of document Binding: ?? (example): High-level kind of document at a macro level. |
| ||||||||
| subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Practitioner | Group | Device) | Who/what is the subject of the document | Σ | 0..1 | Reference(Resource) | Who/what is the subject of the document |
| ||||||||
| date | SΣ | 0..1 | instant | When this document reference was created | SΣ | 1..1 | instant | When this document reference was created |
| ||||||||
| author | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam) | Who and/or what authored the document |
| ||||||||
| authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document |
| |||||||||||||
| custodian | 0..1 | Reference(Organization) | Organization which maintains the document | 0..1 | Reference(Organization) | Organization which maintains the document | |||||||||||
 relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | Σ | 0..* | BackboneElement | Relationships to other documents | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | Σ | 1..1 | CodeableConcept | The relationship type with another document Binding: ?? (extensible): The type of relationship between the documents. |
| ||||||||
| target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | |||||||||
| description | Σ | 0..1 | string | Human-readable description | Σ | 0..1 | markdown | Human-readable description | |||||||||
| securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: ?? (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | Σ | 0..* | CodeableConcept | Document security-tags Binding: ?? (example): Example Security Labels from the Healthcare Privacy and Security Classification System. | |||||||||
| content | SΣ | 1..* | BackboneElement | Document referenced | SΣ | 1..* | BackboneElement | Document referenced | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| attachment | SΣC | 1..1 | Attachment | Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | SΣ | 1..1 | Attachment | Where to access the document | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | id | Unique id for inter-element referencing | |||||||||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||||||
| contentType | SΣ | 0..1 | code | Mime type of the content, with charset etc. Binding: ?? (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | SΣC | 0..1 | code | Mime type of the content, with charset etc. Binding: ?? (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png |
| ||||||||
| language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: ?? (preferred): A human language.
Example General: en-AU | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: ?? (required): IETF language tag for a human language.
Example General: en-AU | |||||||||
| data | SC | 0..1 | base64Binary | Data inline, base64ed | SC | 1..1 | base64Binary | Data inline, base64ed |
| ||||||||
| url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| ||||||||
| size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | Σ | 0..1 | integer64 | Number of bytes of content (if url provided) | |||||||||
| hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||||||
| title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||||||
| creation | Σ | 0..1 | dateTime | Date attachment was first created | Σ | 0..1 | dateTime | Date attachment was first created | |||||||||
| height | 0..1 | positiveInt | Height of the image in pixels (photo/video) |
| |||||||||||||
| width | 0..1 | positiveInt | Width of the image in pixels (photo/video) |
| |||||||||||||
| frames | 0..1 | positiveInt | Number of frames if > 1 (photo) |
| |||||||||||||
| duration | 0..1 | decimal | Length in seconds (audio / video) |
| |||||||||||||
| pages | 0..1 | positiveInt | Number of printed pages |
| |||||||||||||
| format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: ?? (extensible) |
| ||||||||||||
| profile | Σ | 0..* | BackboneElement | Content profile rules for the document |
| ||||||||||||
| context | SΣ | 0..1 | BackboneElement | Clinical context of document | C | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Context of the document content |
| ||||||||
| id | 0..1 | string | Unique id for inter-element referencing |
| |||||||||||||
| extension | 0..* | Extension | Additional content defined by implementations |
| |||||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| ||||||||||||
| encounter | S | 0..1 | Reference(US Core Encounter Profile) | Context of the document content |
| ||||||||||||
| event | 0..* | CodeableConcept | Main clinical acts documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. |
| |||||||||||||
| period | SΣ | 0..1 | Period | Time of service that is being documented |
| ||||||||||||
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: ?? (example): XDS Facility Type. |
| |||||||||||||
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: ?? (example): Additional details about where the content was created (e.g. clinical specialty). |
| |||||||||||||
| sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source |
| |||||||||||||
| related | 0..* | Reference(Resource) | Related identifiers or resources |
| |||||||||||||
| version | Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the DocumentReference |
| ||||||||||||
| basedOn | 0..* | Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription) | Procedure that caused this media to be created |
| |||||||||||||
| modality | Σ | 0..* | CodeableConcept | Imaging modality used Binding: ?? (extensible): Type of acquired data in the instance. |
| ||||||||||||
| event | 0..* | CodeableReference() | Main clinical acts documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. |
| |||||||||||||
| bodySite | Σ | 0..* | CodeableReference(BodyStructure) | Body part included Binding: ?? (example): SNOMED CT Body site concepts |
| ||||||||||||
| facilityType | C | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: ?? (example): XDS Facility Type. |
| ||||||||||||
| practiceSetting | C | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: ?? (example): Additional details about where the content was created (e.g. clinical specialty). |
| ||||||||||||
| period | Σ | 0..1 | Period | Time of service that is being documented |
| ||||||||||||
| attester | 0..* | BackboneElement | Attests to accuracy of the document |
| |||||||||||||
| Documentation for this format | |||||||||||||||||